Healthcare Provider Details

I. General information

NPI: 1497910848
Provider Name (Legal Business Name): RIO GRANDE DERMATOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 ALAMEDA BLVD NE SUITE G
ALBUQUERQUE NM
87113-1591
US

IV. Provider business mailing address

4545 ALAMEDA BLVD NE SUITE G
ALBUQUERQUE NM
87113-1591
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-2900
  • Fax: 505-938-4198
Mailing address:
  • Phone: 505-896-2900
  • Fax: 505-938-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20050405
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20020450
License Number StateNM

VIII. Authorized Official

Name: MS. FRANCINE O MONTANO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 505-896-2900